Vojnosanit Pregl 2013; 70(3): 319–321. VOJNOSANITETSKI PREGLED Strana 319
Correspondence to: Bojana Andrejiý, Center for Pathology and Histology, Hajduk Veljkova 3, 21 000 Novi Sad, Serbia. Phone: +381 21 420 677. E-mail: andrejic.bojana@gmail.com
C A S E R E P O R T S UDC: 616.349-006.326
DOI: 10.2298/VSP1303319D
Lipoma of the sigmoid colon
Lipom sigmoidnog kolona
Matilda A. Djolai*†, Bojana M. Andrejiü†, Dejan Dj. Ivanov‡
*Center for Pathology and Histology, Novi Sad, Serbia; †Department of Histology and Embryology, Faculty of Medicine Novi Sad, Novi Sad, Serbia; ‡Clinic for Abdominal, Endocrine and Transplantation Surgery, Clinical Center of Vojvodina, Novi Sad, Serbia
Abstract
Introduction. Lipoma is a benign tumor of adipose tissue, the most common tumor of the human body soft tissues. As such, it can be found almost anywhere in the human body including the gastrointestinal system (incidence below 0.5%), but rarely in the sigmoid colon. Case report. This is a case report on symptomatic polyp of the sigmoid colon, which after one year, at control colonoscopy, caused suspi-cion to malignancy. Endoscopically diagnosed polipoid le-sion was laparoscopically removed. The pathohistological diagnosis determined benign, submucosal, incapsulated li-poma of the sigmoid colon. Conclusion. Although lipomas of the gastrointestinal tract are rare, this case clearly indi-cates that we should not prematurely and without histologi-cal confirmation of malignancy do more extensive resection for a suspected malignancy.
Key words:
lipoma; sigmoid neoplasms; gastrointestinal neoplasms; diagnosis; diagnosis, differential; laparoscopy; treatment outcome.
Apstrakt
Uvod. Lipom je benigni tumor poreklom iz masnog tkiva i najÿešýi je tip tumora mekih tkiva. Lipom se može naýi u skoro svakom delu tela, nekada i u gastrointestinalnom sis-temu (incidencija ispod 0,5%), ali veoma retko u sigmoid-nom kolonu. Prikaz bolesnika. U radu je prikazan bolesnik sa simptomatskim polipom sigmoidnog kolona. Godinu da-na da-nakon prvog pregleda, kontrolni kolonoskopski pregled izazvao je sumnju u postojanje maligne promene. Endos-kopski dijagnostikovana polipolika promena laparosEndos-kopski je odstranjena. Patohistološkom analizom utvrĀeno je pos-tojanje submukoznog, benignog, inkapsulisanog lipoma si-gmoidnog kolona. Zakljuÿak. Iako su lipomi gastrointesti-nalnog trakta retki, ovaj sluÿaj jasno ukazuje da bez patohi-stološke verifikacije ne treba preduzimati preuranjene i obi-mnije resekcije creva u sluÿaju kliniÿke sumnje na malignitet.
Kljuÿne reÿi:
lipom; sigma, neoplazme; gastrointestinalne neoplazme; dijagoza; dijagnoza, diferencijalna; laparoskopija; leÿenje, ishod.
Introduction
Lipoma is a benign tumor and the most common tumor of soft tissues in human 1, 2. Histologically, lipoma consists of encapsulated mature, white adipose tissue 3.
Lipoma can be found almost anywhere in human body, but most frequent localization is subcutaneous tissue of up-per parts of the body, especially trunk and neck 1, 2. Cases of rare (atypical) lipoma localization have been reported – in-tracranial1, 2, liver 4, myometrium uteri 5, oral cavity 6, and different parts of gastrointestinal system starting from phar-ynx to anal zone 7.
Inside the gastrointestinal system, the highest incidence of lipoma is in the colon, where it represents the second most frequent benign tumor, after adenomas of colon 3, 8.
Gastrointestinal lipomas usually have no symptoms (un-less greater than 2 cm) and are discovered accidentally 8, 9.
Case report
A 64-year-old female patient with body mass index 23.79 kg/m2 was admitted to the Clinic for Abdominal, En-docrine and Transplantation Surgery, Clinical Center of Voj-vodina, Novi Sad. A year before the surgery, due to abdomi-nal pain and occult blood in the stool the patient underwent colonoscopy, and was diagnosed with polypus of sigmoid colon. Colonoscopy after one year showed changes in the part of the intestinal epithelium suspicious for malignancy. After preoperative preparation and analyses, polypus was laparoscopically removed. The patient went through a regu-lar postoperative course.
struc-Strana 320 VOJNOSANITETSKI PREGLED Volumen 70, Broj 3
Djolai AM, et al. Vojnosanit Pregl 2013; 70(3): 319–321.
ture. Polipoid structure and deeper parts of intestinal wall were sampled, fixated in formalin, dehydrated, paraffin em-bedded and permanent paraffin blocks were formed. Paraffin blocks were sectioned to a thickness of 5 micrometers and stained for hematoxylin and eosin (H&E).
The examined material in some sections showed normal intestinal wall structure, while in others colonoscopically registrated, polipoid structure was observed, coated with in-testinal mucosa. In submucosal layer there was demarcated, encapsulated tissue of the tumor, composed only of mature adipocytes without cellularity or atypia (Figure 1). The de-scribed histological feature was typical of lipoma. Tumor tis-sue was elevating mucosa and forming macroscopically de-scribed polipoid formation. Mucosal surface and crypts of mucosa above the polyp were lined with mildly hyperplastic epithelium. The lamina propria contained diffuse, moderate inflammatory infiltrate and erythrocytes.
Fig. 1 – Encapsulated tissue of the lipoma (HE, u40)
Discussion
Lipomas are frequently diagnosed in soft tissues, and are most common in people aged 40–60 years, more fre-quently in females 3, 10.
Of all lipomas in the gastrointestinal system, 65% is lo-cated in the colon, 20%–25% in the small intestine and it is extremely rare in the gaster and the esophagus 11, 12. Most common lipomas are present in the ascending colon (coecum included), transverse colon (including hepatic and splenic flexure), and rarely at the descending and sigmoid colon and rectum 7, 8. Lipomas of the gastrointestinal system are mostly located in submucosa, less in subserosa. The first description of colonic lipoma was given by Bauer in 1757 13.
The appearance of clinical symptoms is related to the dimension of the tumor. Tumor size can range from 1.8 to 3.5 cm, and as symptomatic are generally considered those larger than 2 cm 8, 9. Symptoms may include: abdominal pain (diffused or localised), mechanical obstruction, hemorrhage, constipation 7, 12, 14, 15. There is a report on a case of gastric, antral lipoma prolapsing into duodenum, causing duodenal ulcer 16. Although the patient in this case came with symp-toms frequent in lipoma, it did not lead to proper diagnosis.
Most of lipomas do not require treatment, except for those which rapidly grow or painful symptomatic ones. Available methods for their treatment are endoscopic re-moval of lipoma (diameter less than 2 cm), surgical extrac-tion (diameter > 2 cm, subserosal locaextrac-tion or uncertain diag-nose), steroid injections and liposuction 10, 13.
On the first colonoscopy polipoid structure was de-tected in our patient, but after a year, on control colonoscopy the same polipoid structure brought to misapprehension and suspicion to malignantly altered polypus.
Colonoscopy reveal the condition of the superficial mu-cosa above a lipoma, which in case of erosion, hyperplasia (as in the presented case) or dysplasia of the epithelia may appear to be malignant, and cause repeated colonoscopies and extraction of polypus in spite of biopsies which con-firmed benign nature of the mucosal lesion 9.
From histopathological point of view, a common prob-lem in the diagnosis is the distinction between true lipomas from simple multiplication of adipose tissue. This multiplica-tion is particularly common in the coecum, which is the most common site of lipomas. It is characterized by hypertrophy of adipose tissue in the submucosal intestine wall, which is not encapsulated 3. In the presented case, a lipoma was localized in the sigmoid colon, in which the literature claims, lipomas are rare7, 8. Tumor in the presented case is clearly demarcated and encapsulated which removed the doubt on simple multiplica-tion and hypertrophy of adipose tissue.
Magnetic resonance is considered to be the best imaging method for diagnostic of lipoma, but it is not a part of standard diagnostic algorithm, so most reliable, precise and definitive diagnosis is obtained by histological examination 5.
Typical chromosome abberations were found in lipoma tissue in recent years, but it was impossible to run these tests because all the material from surgery underwent histological procedures.
Although lipomas of the gastrointestinal tract are rare (incidence below 0.5%), the presented case clearly indicates that we should not prematurely and without histological con-firmation of malignancy, do more extensive intestine resec-tion for suspected malignancy. In particular, cauresec-tion should be taken in patients with a history of lipomas at other sites, in obese patients, patients suffering from dyslipidemia and fe-males in menopause 5.
Conclusion
All of the stated above show the difficulties of preop-erative diagnostics of benign lipomas and other malignant le-sions of the colon. Concerning clinical signs and symptoms they are often similar in appearance. Even with abdomen ra-diography and colonoscopy, it is not possible to make a pre-cise differential diagnostic of these states. Only prompt pathohistological examination give a clear insight into the nature of the change and prevents further more aggressive conservative or surgical treatment in case of suspicion of malignancy.
Acknowledgements
Volumen 70, Broj 3 VOJNOSANITETSKI PREGLED Strana 321
Djolai AM, et al. Vojnosanit Pregl 2013; 70(3): 319–321.
R E F E R E N C E S
1. Hoch B, Klein M, Schiller A. Bones and joints. In: Rubin R, Strayer D, Rubin E, editors. Rubin’s pathology: Clinicopa-thologic foundations of medicine. Philadelphia: Lippincot-Williams&Wilkins; 2008, p.1343.
2. Pandya KA, Radke F. Benign skin lesions: lipomas, epidermal inclusion cysts, muscle and nerve biopsies. Surg Clin North Am 2009; 89(3): 677î87.
3. Whitehead R. Gastrointestinal and oesophageal pathology. Lon-don: Churchill Livingstone; 1995.
4. Young S. A case of lipoma of the liver. J Pathol Bacteriol 1951; 63(2): 336î7.
5. Mignogna C, Di Spiezio Sardo A, Spinelli M, Sassone C, Cervasio M, Guida M, et al. A case of pure uterine lipoma: immunohistochemical and ultrastructural focus. Arch Gynecol Obstet 2009; 280(6): 1071î4. 6. Juliasse LE, Nonaka CF, Pinto LP, Freitas Rde A, Miguel MC.
Li-pomas of the oral cavity: clinical and histopathologic study of 41 cases in a Brazilian population. Eur Arch Otorhinolaryngol 2010; 267(3): 459î65.
7. Marra B. Intestinal occlusion due to a colonic lipoma. Apropos 2 cases. Minerva Chir 1993; 48(18): 1035î9. (Italian)
8. Manchikalapati P, Levey J. Suspected asymptomatic large colon lipoma: biopsy? [A case report]. Pract Gastroenterol 2008; 32(3): 35î40.
9. Martin P, Sklow B, Adler DG. Large colonic lipoma mimicking colon cancer and causing colonic intussusception. Dig Dis Sci 2008; 53(10): 2826î7.
10.Gohar A, Salam M.D. Lipoma excision. Am Fam Physician 2002; 65(5): 901î5.
11.Aminian A, Noaparast M, Mirsharifi R, Bodaghabadi M, Mardany O, Ali FA, et al. Ileal intussusception secondary to both li-poma and angiolili-poma: a case report. Cases J 2009; 2: 7099. 12.Nebbia JF, Cucchi JM, Novellas S, Bertrand S, Chevallier P, Bruneton
JN. Lipomas of the right colon: report on six cases. Clin Im-aging 2007; 31(6): 390î3.
13.Mason R, Bristol JB, Petersen V, Lubyrn ID. Gastrointestinal: li-poma induced intussusception of transverse colon. J Gastro-enterol Hepatol 2010; 25(6): 1177.
14.Mnif L, Amouri A, Masmoudi MA, Mezghanni A, Gouiaa N, Bou-dawara T, et al. Giant lipoma of the transverse colon: a case re-port and review of the literature. Tunis Med 2009; 87(6): 398î402.
15.Jovanoviý I, Pavloviý A, Popoviý D, Pavlov M. Endoscopically re-moved giant submucosal lipoma. Vojnosanit Pregl 2007; 64(6): 417î20.
16.Yamane T, Uchiyama K, Furuya T, Ishii T, Omura N, Nakano M, et al. A case of lipoma of the stomach prolapsing into the duodenal bulb and causing a duodenal ulcer. Nippon Sho-kakibyo Gakkai Zasshi 2009; 106(11): 1643î9. (Japanese)
